ABX

The abbreviation for antibiotics.

Allopathic Medicine

The idea that chemistry-related issues are the root cause of most medical problems and that the use of drugs to restore normal chemistry levels will help cure illnesses.

Alternative Therapy

Therapies that are not accepted as “traditional” medicine. Examples include acupuncture, herbal remedies, and meditation.

Applications

The separate components of an electronic medical system, including charting, billing, scheduling, document management, and tracking boards.

ASP (Application Service Provider)

A company that provides a hosted software application that users can access on-demand through a web-browser.

Assessment Section

The portion of the patient record in which a therapy provider documents the patient’s diagnoses and differentials, problem list, goals, and prognosis.

Automated Scoring

Occurs when an application performs calculations automatically using the appropriate equations or formulas. Such calculations may include measurements (e.g., body mass index) or scoring for a particular evaluative test.

Balance Forward

An accounting term referring to the amount outstanding for an account transferred from another billing system.

BFM (Billing Feeds Manager)

The WebPT integration tool that allows the EMR to exchange billing information with multiple outside billing companies.

BMI (Body Mass Index)

A measurement based on a patient’s height and weight. Medical professionals use this calculation to demonstrate the effect a person’s weight has on his or her health.

Capitated Insurance Plans (Capitation)

Insurance plans that pay providers a set dollar amount each month for each patient instead of calculating payment totals based on services rendered. Patients with this type of insurance plan will owe only a nominal copay at the time of service. Such plans put practices at risk because they must manage patient care within the amount they are receiving. Providers may incur penalties for referring patients out to more expensive specialists; thus, these plans place heavy emphasis on preventative care.

Chart Note/Progress Note

A document in which a provider describes the details of a patient encounter.

Chief Complaint (CC:)

The main reason a patient is seeking care, in his or her own words.

Chronic Medical Problems

Any ongoing, long-term medical issues.

CLIA (Clinical Laboratory Improvement Act)

The common term for the laws governing laboratory tests and testing facilities. Typically, a lab must obtain CLIA certification in order to receive reimbursement. Providers must include a lab’s assigned CLIA number when billing for certain lab tests. Thus, they should enter these numbers into their electronic billing systems.

CMS (Centers for Medicare and Medicaid Services)

The government agency for Medicare and Medicaid.

Conversion Factor

The dollar value—to four decimal places—that the Health Care Financing Administration (HCFA) uses as a multiplier to calculate reimbursement rates. The conversion factor is updated annually to account for inflation. Many payers base their reimbursement rates on a conversion factor that is slightly different from Medicare’s.

Copay

The set dollar amount that a patient must pay at the time of service. The amount of a patient’s copay may vary depending on the type of visit.

CPT Code

A nationally-recognized five-digit number representing a particular service provided by a healthcare practitioner.

CPT® (Current Procedural Terminology)

The set of standard procedure codes used in the medical industry.

Cross Platform (platform independent)

Describes a software application that works on more than one kind of system platform (e.g., Mac, Windows, and Unix).

Current Medications

A list of all medications a patient takes on a regular basis.

DO (Doctor of Osteopathy)

A medical professional whose training is similar to that of an MD (medical doctor), but with greater focus on the body’s structure (e.g., the bones, nerves, and muscles). This realm of medicine is based on the idea that problems in these areas often cause illnesses that manipulation may cure. These professionals attend specific osteopathic schools that cover much of the same information as traditional medical schools, with the addition of manipulative therapy. As such, they are qualified to treat the same illnesses that medical doctors treat. Most doctors of osteopathy specialize in primary care disciplines; however, some concentrate on herbal and alternative remedies.

Deductible

The dollar amount a patient must pay out pocket during his or her insurance coverage period (typically one year) before the insurance will begin to pay claims.

Differential Diagnosis (DDX)

A list of possible diagnoses. For example, if a patient receives a general diagnosis of chest pain, but the provider orders additional tests to rule out other, more specific diagnoses, the provider would list the differential diagnosis to indicate that he or she is considering several possibilities.

DME (Durable Medical Equipment)

Medical equipment a patient uses in the home to help achieve a better quality of living. Such equipment usually can withstand repeated use. Examples include wheelchairs, crutches, or nebulizers. These are specific billed using specific Healthcare Common Procedure Coding System (HCPCS) codes called E codes.

Document Imaging

The process of converting paper documents into an electronic format, usually by scanning them.

Document Management

The process of scanning, categorizing, and storing vital patient documents.

Dx

The standard abbreviation for diagnosis.

E Codes

Healthcare Common Procedure Coding System (HCPCS) codes used specifically for durable medical equipment (DME).

E&M (Evaluation and Management) Codes

Codes that define a visit type (e.g., level-3 office visit). E&M codes comprise a subset of CPT® codes.

EDI (Electronic Data Interchange)

Electronic communication between two parties, generally in relation to the filing of electronic claims to payers.

eDoc (External Documents)

The WebPT feature that allows clinics to store outside documents (e.g., patient consent forms or insurance card copies) within the EMR. Members simply scan documents to create PDFs and then upload the electronic files into the patient chart.

EMR (Electronic Medical Records); also known as EHR (Electronic Health Records) or CPR (Computerized Patient Record)

A digital record of a patient’s medical record, including his or her clinical, demographic, and administrative information.

EPSDT (Early and Periodic Screening, Diagnosis and Testing)

A Medicaid term referring to well visits, immunizations, and other standard childhood procedures aimed at improving the health of low-income children.

Family History

A compilation of the medical history—including chronic medical conditions—of a patient’s immediate family members (e.g., parents, siblings, and grandparents).

Fee Schedules

A comprehensive list of all CPT® and HCPCS codes and their corresponding charges. This list may vary based on insurance and negotiated rates.

GPCI (Geographic Practice Cost Index)

A regional weight assigned to a Medicare locality to account for the cost of delivering services in that area. Each relative value unit (RVU) component has a specific weight, with 1.00 being the mean. (Therefore, 0.9 would reflect a lower cost base, and 1.1 would be higher.) The GPCI serves as a multiplier in the equation used to calculate Medicare’s allowable reimbursement rate.

Guarantor

The person ultimately held responsible for a medical bill after the patient’s insurance has made its contribution.

GUI (Graphical User Interface)

A software program’s user-facing interface and design.

HCFA (1500) Form

The standard insurance claim form that most—though not all—insurance carriers use when submitting paper claims.

HCFA (Health Care Financing Administration)

The government body that controls and directs legislation for government-sponsored health coverage, including Medicare and Medicaid. HCFA also determines many of the reimbursement rates upon which other payers base their rates.

HCFA-1450

Commonly known as the UB-92 (Universal Bill), this insurance claim form is used for hospital visits and rural health claims. It features more procedure-level reporting lines than other claim forms and provides a place to enter information regarding a patient’s hospital stay (e.g., number of days).

HCPCS (HCFA Common Procedural Coding System)

A code set that includes codes for supplies, materials, and injections (e.g., bandages, rubber gloves, and penicillin). These are reported in the same areas of insurance forms as CPT® codes (or with HCPCS, the same area as Level II CPT® codes). There are specialized HCPCS codes—such as E, J, and L codes—for specific procedures or services.

Health Summary

A summarized record of a patient’s medical history, including past diagnoses and treatments, chronic medical problems, current medications, drug allergies, and family and social history.

Help Desk

The service and support platform for a program or application.

HITECH Act (Health Information Technology for Economic Clinical Health Act)

A piece of legislation that gives the US Department of Health and Human Services (HHS) the authority to establish programs to improve healthcare quality, safety, and efficiency through the promotion of health information technology (HIT), including electronic health records and private and secure electronic health information exchange.

HPI (History of Present Illness)

The patient's description of the symptoms related to the condition for which he or she is seeking medical attention. Pre-made documentation templates often include a space for HPI.

HTN

Abbreviation for hypertension or high blood pressure.

Hx

Abbreviation for history or medical history.

ICD-9 (International Classification of Diseases) Codes

The diagnosis coding set currently in use in the United States. To ensure reimbursement, providers and billers should use the most specific diagnosis code available.

Integration

Occurs when two applications connect and exchange data securely.

Interoperability

Occurs when end-users across a variety of domains, networks, facilities, and hardware can successfully communicate with one another.

ISP (Internet Service Provider)

A company or service that provides an Internet connection.

MA (Medical Assistant) or CMA (Certified Medical Assistant)

Clinical professionals whose responsibilities often include working up patients, triaging and returning patient calls, and offering general assistance to the provider.

MD (Medical Doctor)

A professional licensed to practice medicine.

Meaningful Use

A set of standards governing the use of certified electronic health records (EHRs) to improve the quality, safety, efficiency, and accuracy of healthcare delivery as well as improve care coordination, communication with patients and their families, and overall public health. Meaningful use is part of the HITECH Act.

Medicare Locality

A region of the United States (e.g., state or metro area) that HCFA has defined as having a particular cost structure. Because different localities may have different GPCI weights, they also may have different reimbursement rates.

Mid-level Practitioner

The class of healthcare providers considered to be a level below medical doctors and doctors of osteopathy. Such providers include physician assistants and nurse practitioners.

Modifier

A two-character code added to a CPT® or HCPCS code to offer additional information regarding procedures and reimbursement. Each CPT® code can have up to four modifiers attached to it, although in most cases only one or two are necessary.

MPT

Abbreviation for master of physical therapy.

NP (Nurse Practitioner)

A mid-level provider whose education includes a bachelor's degree and a rigorous three-year training program led primarily by advanced nurses. NPs must have physician supervision. Although they can specialize in certain fields (e.g., pediatrics or family medicine) they are somewhat limited.

NKDA or NDA

Abbreviation for no known drug allergies.

NPI (National Provider Identifier)

The eight-digit alphanumeric identifier given to all medical facilities. While some medical doctors and doctors of osteopathy still use UPIN numbers instead of NPI numbers, most mid-level practitioners have NPIs.

NSF (National Standard Format)

The standard format for electronic filing.

Objective

The section in WebPT's Documentation module where therapists record their findings during patient encounters. The objective section includes exam findings, special tests, and measurements for strength, range of motion, and flexibility.

Office Visit Levels

Coded with E&M codes, these levels range from level I to level V depending on complexity, with V being the most complex.

OMT (Outcome Measurement Tool)

A measure of the quality of care. Practitioners use OMTs to establish a baseline of patient health or function and assess the effectiveness of the treatment provided. Providers must complete outcome measurements for all Medicare patients at the initial evaluation, at specific intervals throughout the episode of care, and at discharge.

PA (Physician Assistant)

A mid-level provider whose education includes a bachelor's degree and a rigorous three-year training program led primarily by physicians. Although a PA is not a physician, in most states, PAs have rights and privileges similar to those of doctors. However, they require physician supervision.

Past Medical History

A list of a patient’s previous health issues, surgeries, specialists, and other medical-related information.

Patient Demographics

A patient's basic administrative information, including his or her name, date of birth (DOB), Social Security number (SSN), insurance, address, and contact information.

Payer

Any party responsible for payment of services rendered. This could be an insurer, the patient, or another party.

PCN

The medical abbreviation for penicillin.

PCP (Primary Care Physician)

The main provider who manages a patient's health. In most cases, this is a family practitioner, internist, general practitioner, or pediatrician. The PCP generally is responsible for referring patients to specialists as needed.

PEFR (Peak Expiratory Flow Rate)

The rate, in liters per second, at which air moves out of a patient's lungs at the beginning of expiration. Also known as peak flow.

Plan

The section WebPT’s Documentation module where therapists record the treatment they are prescribing, including recommendations and any relevant testing.

Point and Click

The computer action that involves pointing a cursor or mouse to a certain area of the screen and then clicking on it.

Posting

The process of generating patient charges and recording payments.

PQRS (Physician Quality Reporting System)

A reporting program requiring eligible professionals (EPs) to meet certain standards of quality data submission. Failure to do so results in financial penalties in the form of payment adjustments.

Practice Management

A category of software healthcare providers use to manage the day-to-day operations of their practices. Such software typically includes scheduling, billing, reporting, and operational management.

Private Pay

Describes patients who choose to pay out-of-pocket for the care provided.

Progress Note

A document in which a healthcare professional records details about a patient's clinical status. PTs use this document to update physicians regarding patient progress.

Provider Login

The username and password providers use to access their electronic medical records.

Provider (or Provider of Service)

A general term for someone who provides medical services (e.g., a medical doctor, doctor of osteopathy, nurse practitioner, or physician assistant).

Dropdown Menu

A list of commands or options that appear when you hover or click your mouse on a particular area of your computer screen.

Query

The process of using search functionality to retrieve information from a database.

RBRVS (Resource Based Relative Value Scale)

A scale of “weights” assigned to particular CPT® codes to indicate the relative degree of effort required to perform each corresponding procedure. This scale accounts for the cost of supplies, the risk or difficulty level of the procedure, and the time spent on the procedure. The Health Care Financing Administration (HCFA) controls the RBRVS.

Referral

A situation in which one healthcare provider sends a patient to another provider for treatment. Some insurance companies require referrals for certain procedures. Referring Provider A medical provider who refers a patient to another medical provider—often a specialist—for a specific procedure or treatment.

Rendering/Performing Provider

A practitioner who is providing treatment to a patient.

Risk Pool

An agreement among practices in which a certain percentage of each provider’s reimbursements goes into a fund reserved for unexpected expenses. Unused funds are eventually distributed back to the participating practices according to productivity, profitability, and other factors that reward efficient operations.

ROI (Return on Investment)

Typically characterized by money in versus money out, ROI is a performance measure used to determine the effectiveness of a campaign, initiative, or endeavor in terms of resources invested (e.g., time, money, labor).

ROS (Review of Systems)

A series of questions related to the specific system(s) that the patient is having issues with (e.g., respiratory system for cold symptoms).

RHC (Rural Health Clinic)

A health clinic that is contracted by the Health Care Financing Administration (HCFA) to provide services to underserved populations and are therefore reimbursed at a slightly higher rate than the normal Medicare allowable fee schedule. RHCs receive a special status, bill particular procedures with QB (rural) or QU (urban) modifiers, and submit claims using UB-92 forms.

RVU (Relative Value Unit)

Part of the resource-based relative value scale (RBRVS) used in the Medicare reimbursement formula for physician services, RVU is the weight assigned to a particular CPT® code. The Total RVU for a CPT consists of the Work RVU (the amount of time and effort required), the Practice Expense RVU (the overhead cost of that time), and the Malpractice RVU (the likelihood of complications).

SaaS (Software-as-a-Service)

A distribution model where access to a software and its services are on-demand and available through a subscription. Example of SaaS include Netflix, SalesForce, and WebPT.

Scalable

How effectively software and/or hardware can adapt to increases in demand and activity.

Security

In the case of technology, security refers to the level protections in place to protect user information and data.

Server-Based

A type of software that users must download or acquire on CD and then install on their computers and onsite servers. To use the software and transmit data, the users’ computers must always be connected to the servers. In the case of an EMR, this means that all data is stored locally, and the clinic is responsible for maintaining the servers, upgrading the software, and troubleshooting technical issues.

Single Sign-On

The ability to sign in to access multiple systems without needing to enter multiple user names and passwords.

SLP

Speech language pathologist

SOAP Note

A documentation note format commonly used in physical, occupational, and speech therapy. It consists of Subjective, Objective, Assessment, and Plan sections.

Social History

A patient's social habits and history including marital status, alcohol and drug use, and exercise habits.

Subjective

Consisting of the chief complaint, HPI, and ROS, subjective is a section within the SOAP note where the therapy professional documents the patient's description of his or her current problem.

Superbill

Also known as an encounter form, route slip, or fee slip, a superbill is a printed form used to document coding for a specific patient visit. It features patient information at the top and a subset of the provider's/practice's most commonly used ICD and/or CPT® codes. The form travels with the patient throughout the clinic. Providers check off items when they see the patient, and the form then travels to the checkout desk or billing office where the codes are entered into the billing system.

Supervising Provider

The healthcare professional responsible for overseeing patient care.

Sx (symptoms)

A physical or mental sensation or feature that a patient experiences. Healthcare providers use symptoms to establish a diagnosis.

System Administrator

The WebPT user(s) within a particular clinic group who has the highest level of permissions and accessibility.

Tablet PC

Similar to an iPad, a tablet PC is a mobile device that features an Android, Google, or Microsoft operating system as well as a touchscreen. Typically, users can connect keyboards to these devices or use a stylus on the touchscreen. These devices can connect to WiFi or a mobile network (e.g., 3G, 4g LTE).

Template

Often referred to as a “library” or “dictionary,” templates are a pre-defined selection of choices or fields designed to streamline the process of documentation.

Till Reconciliation

Used for balancing A/R, this report details money posted or expected versus money actually received.

Time Grid

A way of presenting a specific provider's patient schedule. Time grids typically specify how many appointments the front office can book for that provider per day as well as appointment length.

TOPS (Total Office Paperless Solution)

Using all electronic equipment, services, and applications to manage a clinic.

Trial Balance

A detailed report of all invoices for a single patient.

UPIN

A standard six-digit alphanumeric identifier assigned to healthcare providers either as single provider or a group/facility.

Uptime

The average amount of time a system is functioning at full capacity and available for use. When this number is presented as a percentage, it’s referred to as “uptime rate.”

Wave Scheduling

The act of scheduling patients in groups, or waves, as opposed to one at a time, or stream. Because patients rarely arrive on time, some practices schedule multiple patients at the same time with no appointments booked in the subsequent time slot. Another version of wave scheduling, called modified wave scheduling, is based on the actual time a provider spends with each patient and involves scheduling smaller waves at intervals throughout the hour. Both methods ensure a ready supply of patients, thus minimizing physician downtime that no-shows and late arrivals can cause.

Web-based

When an application, service, or software is accessible via web browser and available through any Internet connection. Pandora, Charles Schwab, and Gmail are all examples of web-based applications.

WiFi

Through a local network, Internet-enabled devices can transmit data or access the Internet wirelessly. This is also known as wireless Internet.

Workflow Automation

This occurs when a technology solution or software converts a process—such as SOAP note documentation or patient appointment reminders—into an automatic operation.

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